Effects of Mindfulness Meditation on Quality of Sleep, Perceived Stress, Serum Cortisol, and C-reactive Protein in Hemodialysis Patients

End-stage renal disease (ESRD), or kidney failure, happens when the kidneys almost completely stop working, usually below 10-15% of normal function. It has been documented as a significant factor in rising rates of disability and mortality worldwide, particularly due to the rising rates of diabetes and hypertension. Globally, the population of individuals with ESRD falls from 4.902 to 9.701 million, with most found in low and middle-income nations. In North Africa and the Middle East, ESRD rates exceed 500 per 100,000 population when age-standardized. In Gulf Cooperation Council (GCC) countries, the average rate of end-stage renal disease was 551 per million people, with Oman having the highest prevalence at 1000 per million and Qatar the lowest at 347 per million. In Kuwait, there were 465 cases of dialysis per million people, while the incidence of dialysis was 100 per million populations.

The Global Burden of Disease reports that impaired fasting plasma glucose, hypertension, sodium-rich diet, heart disease, urinary tract blockages, inflammation, and certain genetic disorders are common risk factors for end-stage kidney disease. The last phase of chronic kidney disease necessitates renal replacement therapy, like dialysis or a kidney transplant, to ensure survival. Both forms of dialysis, hemodialysis or peritoneal dialysis, effectively eliminate toxins and excess fluids from the body, but they do not cure kidney disease. Nevertheless, hemodialysis is an extremely important treatment for individuals with ESRD that enhances health by removing toxins from the body, typically done multiple times a week and lasting several hours.

However, the lives of ESRD patients are impacted by hemodialysis treatment, which brings about various physical and psychosocial stressors during their lengthy treatment. In relation to physical indications, hemodialysis patients are constantly in danger of experiencing intradialytic hypotension, muscle cramps, headache, fatigue, nausea, vomiting, itching, acute hemolysis, air embolism, bloodstream infections, and vascular access stenosis. While stress, insomnia, depression, and anxiety are among the psychological indicators in this group. Additionally, most of these individuals have observed elevated amounts of pro-inflammatory markers in the blood, like C-reactive protein. In this situation, continual stress can harm the immune system by activating the hypothalamic-pituitary-adrenal (HPA) system, including hormones like cortisol, which rises 15 minutes after the stress situation and stays high for multiple hours. During chronic stress and frequent exposure to stressors, a long-term elevation in cortisol levels can harm the hippocampus, reduce sensitivity to cortisol, and enhance cortisol binding to the mineralocorticoid receptor. When cortisol binds to the mineralocorticoid receptor, it triggers the release of pro-inflammatory factors like C-reactive protein (CRP) as a pro-inflammatory response and psychological stress. It often leads to changes in body fluid balance, uremia, and frequent nocturnal muscle cramps, all of which disturb sleep. As the hemodialysis treatment often involves three or more sessions per week, each lasting several hours, it is taxing on the patient's body and disrupts natural circadian rhythms, compounding the effects of sleep disorders. Sleep disorders such as insomnia, restless leg syndrome, and obstructive sleep apnea are common among hemodialysis patients, leading to fatigue, cognitive decline, and increased risk for depression and anxiety. Additionally, poor sleep can exacerbate cardiovascular risks, worsen pain perception, and weaken the immune system, all of which are critical concerns for ESRD patients. These issues are particularly problematic because they affect patients' rest, physiological recovery, and mental health. That's why sleep quality is often severely impaired in patients with ESRD, with rates of sleep disturbances much higher than in the general population or among those with other chronic illnesses.

As a result, reports have shown that ESRD patients sometimes employ ineffective or harmful coping strategies when facing multiple stressors, resulting in negative impacts on their overall physical and psychological well-being, increased vulnerability to infections, and higher rates of mortality and morbidity among this population. On the other hand, mind-body techniques are believed to be beneficial for health by promoting a connection between the mind and body, enhancing present-moment awareness and acceptance without judgment. Mindfulness meditation, a widely practiced mind-body technique, involves focusing on the present moment with an attitude of acceptance and nonjudgment. Mindfulness meditation is hypothesized to target multiple cognitive and emotional processes that contribute to stress and poor sleep quality. It has been shown to enable psychological distance and positive reappraisals, helping to stop automatic, uncontrollable appraisals and decreasing stress and cortisol levels. It has also been shown to decrease ruminative thoughts, diminish emotional reactivity, and promote impartial reappraisal of salient experiences, which together may facilitate sleep. In addition, it has been found to improve physiological indices of stress by cultivating stress and amygdala reactivity, resulting in decreased cortisol responses and pro-inflammatory markers such as CRP. Decreased amygdala reactivity associated with activation of the parasympathetic nervous system decreases cortisol levels, which is its high prolonged levels can cause an increase in glucocorticoid receptor resistance to cortisol and increased circulating markers of inflammation, such as CRP.

Smith suggested in his Attentional Cognitive Behavioral (ABC2) Relaxation theory that two 30-minute sessions of mindfulness meditation per week are necessary to induce relaxation, reduce stress, and enhance overall health on the broader community. His mindfulness format has been suggested as a standardized format with five consecutive parts, each lasting 5 minutes, for a total session time of 30 minutes. Research has shown that this mindfulness meditation is as successful as the more extended method in decreasing stress levels. Also, mindfulness meditation has been shown to be a suitable therapy that improves various aspects of well-being in Arabic societies. In general, studies have shown that mindfulness meditation is a proven method to decrease stress and biomedical markers and improve sleep quality in both ESRD and other chronic patients, impacting them physically, emotionally, and mentally.